Audit: Care home needed closing

A Cary adult-care home was putting residents at such high risk of injury or death that state regulators should not have allowed it to keep its license, state auditors said Tuesday.

But the facility, Parkway Retirement Home, was allowed to remain in operation despite 23 care violations and two ownership "changes" that left one of the same owners in place after Parkway's license was temporarily suspended in June 2007.

The center continues to operate under the name Phoenix Assisted Living.

"Based on the continuing citations assessed against this same adult care home, the risk is high that improper operations will persist as long as a similar management structure continues," state Auditor Les Merritt said in a letter to DHHS Secretary Dempsey Benton.

Merritt faulted the Adult Care Licensure Section of the state Department of Health and Human Services for failing to take appropriate action.

"These citations could lead to resident injuries or death as they did in May 2007," Merritt wrote, referring to the death that month of Thomas Pfirman, a retired civil engineer and Vietnam veteran who strangled in his bedrails.

State investigators found Parkway at fault after learning that Parkway staff failed to take precautions after a similar incident a month earlier sent Pfirman to the emergency room.

"Either the state is letting it happen or the state is so busy and so underfunded that things fall through the cracks," Pfirman's son, Nick, said Tuesday. "I definitely think there are greedy people who take advantage of those cracks."

Benton acknowledged the problems described in the audit and said the department would address their root causes.

Autry Butler, an owner of Parkway who has stayed on in the facility's new incarnation as Phoenix Assisted Living, said the center has turned around since the new license was issued last year.

"The facility has made dramatic improvements," Butler said. "What they were concerned about at the time has not borne fruit."

According to state records, another resident risked death in a June 2007 case, when Parkway staff mistakenly cut off a patient's medicine for hypertension, pain, dementia and depression, although his doctor only wanted him off Tylenol. That case, along with Pfirman's death, have drawn penalties of $16,000 from state regulators.

Additional substantiated complaints about care occurred in October, November, December and February, said Gail Holden, director of adult services for Wake County Human Services.

"They've got a nice little list going there," Holden said, adding that investigators are seeing a pattern of noncompliance.

Holden said the situation shows how companies have learned to sidestep rules meant to keep bad operators from getting new licenses. Owners who have gotten into regulatory trouble have often rotated family members and other associates in and out of ownership to make it appear that changes have occurred, she said.

"The technicalities have allowed the spirit of what they intended to fall by the wayside," Holden said.

In another case, auditors found that the state allowed an unlicensed home in Wake County to remain open for more than six months after the state received a complaint that the center was caring for two residents despite the lack of a license. The center was not identified in the report.

The audit found that DHHS failed to let residents' relatives and caregivers know that the unlicensed center had gotten a letter ordering it to stop feeding and giving medications to residents.

"Notification of responsible persons is an important step in the process of removing residents expeditiously from an environment where there is a risk of endangering their health and safety," Merritt said in the letter.